New care model targets high-utilizing patients
Center aims to better match resources, needs
While EDs are designed to respond to acute care needs, they are often inundated by patients with complex medical, social, and behavioral health problems that require comprehensive solutions. Not surprisingly, the results of this mismatch can involve long wait times, inefficient care, and less than satisfactory outcomes. Further, lacking good alternatives, many of these patients return to the ED time and time again, taking up expensive resources that are often not a good fit for their needs.
However, with new payment reforms on the horizon, some health care systems have taken steps to short-circuit such patterns of utilization and redirect these complex patients into care pathways that will better meet their needs. For example, Hennepin County Medical Center (HCMC) in Minneapolis is winning kudos for its Coordinated Care Center, a clinic located on the hospital campus that is rolling out the welcome mat for those very same high-utilizing patients who are well known to emergency providers and hospital staff.
Administrators say that while the infrastructure is not yet in place to make the model a financial winner, the approach is credited with slashing ED visits by 37% and inpatient care stays by 25% after one year of operation, according to the National Association of Public Hospitals (NAPH), which recently honored HCMC and its Coordinated Care Center (CCC) with the 2013 Gage Award for Improving Public Health. What’s more, the model offers a glimpse of what can be accomplished when hospitals and EDs are tightly integrated with the kind of outpatient and community resources that complex patients need to stabilize and make progress.
Troubling utilization patterns are what initially prompted administrators at HCMC to develop the CCC. They found that roughly 7% of the hospital’s patients were responsible for 30% of the cost of care, and much of this expense was due to preventable hospital admissions and frequent ED visits. Administrators found that these high-utilizing patients were typically low-income adults with complex medical, social, or behavioral health problems.
Informed by these demographics, the CCC was set up to deliver the kind of comprehensive services that these patients need, explains Lisa Fink, RN, CNM, JD, the program practice manager for the CCC. "Our focus is on people who have a diagnosis that is primarily medical, such as CHF [congestive heart failure], COPD [chronic obstructive pulmonary disease], or diabetes," she says. "The way someone is eligible for care here is they have had three hospital admissions, and they are usually associated with lots of ED visits and very few visits to a primary care provider [PCP]. They usually aren’t hooked up with a PCP at all."
Such patients are typically flagged by the health system’s electronic health record at the point of admission. An RN clinical coordinator from the CCC will visit with a patient while he or she is still in the hospital, review the chart to make sure that the patient is a good candidate, and then invite the patient into the clinic; the patient will then come to the clinic for a discharge visit after he or she leaves the hospital, explains Fink.
Two RN clinical coordinators also keep an eye out for these high-utilizing patients at the point of triage in the ED at HCMC, a level 1 trauma facility that sees about 100,000 patients every year. "They are looking constantly for [new] patients, as well as identifying patients who are well-known to them," says Kathleen Moore, RN, MSN, the nurse manager in the ED/urgent care center at HCMC. An emergency physician can also bring an ED-based clinical coordinator in on a case at the back end. Moore adds that the ED-based clinical coordinators are accessible in the hospital until 11 p.m., seven days a week, and they are on call 24/7.
When a patient is a good candidate for the CCC, the ED clinical coordinator will facilitate the transition right away if the patient’s primary complaint can be better handled in that setting. "I really feel like we are getting the patients to where they need to be, and that they are also getting additional services that the ED wouldn’t necessarily be able to provide," says Moore. "Even if the patients are seen in the ED, the clinical coordinators are able to arrange all the things they will need as far as follow-up, which definitely better serves the patients."
Moore stresses that the ED-based clinical coordinators have made a huge impact in terms of freeing up emergency providers to take care of patients with acute care needs while also connecting patients with more appropriate sources for the care they will need following the ED visit. "In the past, I don’t know that we did the best job we could do as far as [arranging] follow-up," says Moore. "We really were leaving patients with no other alternative than to be utilizing the ED."
Facilitate access, relationship-building
Those patients who meet the criteria to be seen by the CCC get plugged into the kind of multidisciplinary care that they have been lacking, even while heavily consuming inpatient and ED resources. Fink describes the CCC as an ambulatory intensive care unit, with an on-site pharmacist, social worker, psychologist, and chemical health counselor, as well as physicians, nurse practitioners, LPNs and patient navigators — enough personnel to comprise two full care teams.
"When patients come in they are usually here for 90 minutes or so. They will see either a physician or a nurse practitioner, and they also might see the psychologist. Then [the psychologist] might suggest that they also stop in and see the chemical health counselor because he might have some good resources for the patient," says Fink. "It is like a one-stop shop. We even have a dental clinic one morning a week."
The social workers spend a lot of time connecting patients with housing because many of them are either homeless or living on someone’s couch when they first come in, notes Fink. "It is such a critical piece to being able to stay healthy," she says.
"The individuals who come to our clinic have been frequent utilizers of the ED, and they certainly continue to use it some, so we have a relationship with the clinical coordinators there," says Fink, noting that if a CCC patient presents to the ED for care, the ED clinical coordinators will be in touch. "One of us will walk over to the ED, and if the patient is stable enough to be seen in the CCC instead of the ED, then we will walk him back over to our clinic and see him here. There is a lot of back and forth communication."
Patients who agree to be seen in the CCC will receive guidance about when to use the CCC for care versus the ED, and they are given broad access. The CCC is open from 8 to 5 during weekdays, and patients can either make appointments or walk right in, says Fink. Further, when patients need to contact the CCC, they are not funneled through the health system’s general contact line; they call the CCC directly. "The person who picks up the phone, they probably know," says Fink. "For patients who have historically not trusted the health care system, and have not used it in a way that was most effective, we want to maximize the relationship-building, so we answer our own phones." In some instances, the CCC will also equip patients with phones, adds Fink.
While the CCC is currently not open in the evenings or on weekends, Fink says there will soon be a call system in place so that patients can reach a CCC provider during off hours. Even without the call system, though, Fink stresses that running the CCC requires tremendous flexibility on the part of staff. "It really is an ambulatory ICU. That’s what a lot of people refer to it as," she says. "It is pretty intense with all of the comorbidities going on."
Take a broader view of health
The contributions of the two ED-based clinical coordinators have made a significant impact on the ED, says Moore. While not all of the patients they intervene with require or qualify for care in the CCC, the clinical coordinators have been instrumental in matching patients with the specific resources they need. For example, Moore notes that in the past, a patient who was seen and treated for a wound in the ED would have had few options for follow-up other than to return to the ED for needed dressing changes. However, now the ED clinical coordinator steps in to arrange for this type of follow-up in an urgent care setting or another clinic that is accessible to the patient.
"They have been very instrumental [in eliminating] those repeat visits for things that clearly don’t have to be looked at again by the ED staff, but definitely need to be done to obtain better patient outcomes," says Moore. "We want to grow our volume, but we want people to be in the right places. We want the people who are acutely ill and definitely in need of emergency services to have that fast response through our front door, so decreasing utilization for non-urgent visits is huge. It helps deliver better outcomes for the acutely ill."
Currently, the CCC cares for about 240 patients, although Fink anticipates that the number will grow significantly. "We know there are a lot more people out there who meet the criteria — heavy utilizers of the ED and inpatient use, and people we feel we could help," she says.
To accommodate growth, Fink acknowledges that the CCC needs more mental health practitioners and access to more community resources such as sober housing and respite care. "A lot of this is really a broader sense of what makes health," she says. "What we mostly need is a new payment model because we don’t get paid for what we think makes the most difference, and that is real, on the ground, consuming care coordination. It takes a huge amount of time; it is not just a phone call once a month, but we can’t bill for that."
However, Fink notes that HCMC is continuing to support the model with resources. And administrators believe the approach will pay off as payment reforms focus more on the total cost of care. "This is absolutely in line with where we are heading, but we are not there yet," she says. "This is quite a leap of faith. It is really about saying that this is the right thing to do."
- Lisa Fink, RN, CNM, JD, Program Practice Manager, Coordinated Care Center, Hennepin County Medical Center, Minneapolis, MN. E-mail: firstname.lastname@example.org.
- Kathleen Moore, RN, MSN, Nurse Manager, Emergency Department/Urgent Care, Hennepin County Medical Center, Minneapolis, MN. Phone: 612-873-3000.